A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Check the client's distal pulses in both legs.

Keep the client overnight.

Keep the client on bed rest for 12 hr.

Restrict the client's oral fluids.

Answer and Explanation

The Correct Answer is A

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

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Correct Answer is D

Explanation

A. Abuse:

Abuse typically involves intentional harm or mistreatment of another person. In this scenario, the nurse's error was inadvertent, not intentional, so it does not constitute abuse.

B. Battery:

Battery involves intentional harmful or offensive contact with another person without their consent. The inadvertent medication error in this scenario does not involve intentional contact or harm, so it does not constitute battery.

C. Assault:

Assault involves intentionally threatening or causing fear of immediate harm or offensive contact with another person. The inadvertent medication error, while resulting in harm, was not intentional or intended to cause fear, so it does not constitute assault.

D. Malpractice:

Malpractice refers to professional negligence or failure to adhere to the standard of care expected in one's professional duties, resulting in harm to a patient. In this scenario, the nurse's inadvertent medication error constitutes malpractice because it involved a breach of the standard of care expected in medication administration, resulting in harm to the client.

A. Ferrous sulfate B. Heparin C. Prednisone D. Vitamin K

Correct Answer is D

Explanation

A. Ferrous sulfate: Ferrous sulfate is an iron supplement used to treat or prevent low blood levels of iron (such as those caused by anemia or pregnancy). It is not used to treat high INR levels.

B. Heparin: Heparin is an anticoagulant, or blood thinner, that prevents the formation of blood clots. It would not be used to treat a high INR level, as it could potentially increase the INR even further.

C. Prednisone: Prednisone is a corticosteroid that reduces inflammation in the body. It is not used to treat high INR levels.

D. Vitamin K: This is correct. Vitamin K is used to help blood clot and is given to patients who have a high INR level to reduce the risk of bleeding. Warfarin works by blocking the effects of vitamin K, so giving vitamin K can help reverse the effects of warfarin and lower the INR.

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